Provider Demographics
NPI:1619205150
Name:JACKSON, CHARNEL LAZETTE (MA)
Entity Type:Individual
Prefix:MS
First Name:CHARNEL
Middle Name:LAZETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6820 CELIA DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-1133
Mailing Address - Country:US
Mailing Address - Phone:225-235-6281
Mailing Address - Fax:
Practice Address - Street 1:4787 WAYWOOD DR
Practice Address - Street 2:#C
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2480
Practice Address - Country:US
Practice Address - Phone:225-654-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3661101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional